Helping health plans create a healthier system

Health Data Essentials delivers quality-of-care insight with SAS

As part of the sweeping health care reform law in the United States, the Patient Protection and Affordable Care Act encompasses many provisions, including a series of quality initiatives aimed at measuring, tracking and improving the quality of care delivered by privately operated Medicare Advantage plans. Based on their ability to improve the quality of care delivered to their members, health plans will have the opportunity to obtain quality bonuses. To help US health plans meet the federal government’s quality-of-care targets, as well as qualify for Medicare incentives, Health Data Essentials – a consultancy providing analytical services, such as quality measurement, financial modeling and revenue management – is using SAS® Business Analytics to help clients track their performance against quality-of-care metrics.

"The application we built is in response to the health reform legislation," explains Richard Lieberman, CEO, Health Data Essentials. "Congress came up with a five-star quality rating system. If a plan gets three, four or five stars they will get additional bonus payments for each of the members they have enrolled."

And with $5 billion in funds available annually, it behooves health plans to rally around the government's quality measurement program.

There are significant technical advantages to using SAS for this sort of work – we would not be this far in such a short amount of time without using SAS.

Richard LiebermanCEO

Enhancing the patient experience

According to Lieberman, the government is asking health plans to focus their efforts on helping members by promoting the Triple Aim, to improve the population's health, while enhancing patient experience and controlling the cost of care. This means tracking measures such as the percentage of women receiving mammograms, the percentage of people receiving colorectal screenings, or simply member visits to a primary care doctor in one calendar year.

"You can't get everyone; you just have to reach a reasonable threshold," Lieberman says. "In the case of mammograms, the government wants health plans to reach an 82 percent compliance rate, which would give a plan a five-star rating for that metric. To receive incentive payments in 2012, plans need to achieve at least a three-star rating as an average on all of their measures."

Tracking quality

And to help health plans track their quality measures throughout the year, Health Data Essentials, supported by Zencos, a SAS Alliance partner, built a business intelligence system, EssentialStars™, that provides up-to-date data on quality metrics, allowing clients to easily access their data to monitor their progress and to implement any changes needed to improve performance. When needed, the firm's health care consultants can also help clients implement initiatives to improve their quality of care.

Lieberman says the government's program will have a positive effect on ensuring providers are delivering the right kind of preventative care, instead of only delivering episodic specialty care. The incentives aid health plans in changing the behavior of providers and patients by encouraging patients to schedule preventative screenings.

By gathering claims data, survey data and medical record review data, Lieberman's team is delivering reports to clients through the EssentialStars™ web portal, which can be used by health plan staff members to drill down to the plan, provider and member level.

"An underlying premise of the system is that if you're going to get in front of doctors to try and impact how they practice medicine or in front of a patient to impact their care decisions, you have to reach them in one go because you don't get that many chances for interaction. So we built a complete medical management platform into the system that uses predictive analytics to identify things such as avoidable hospitalizations and emergency room encounters. It also helps to achieve cost savings because if you do preventative care better, costs go down."

Mobile health insight

In addition, the system can be accessed through smart phones and handheld devices, allowing providers to easily review current patient information before going into an examination room.

"They can look at preventative measures that the patient might need, as well as patient utilization of services that may not be in the doctor’s medical records – they can see more of the patient’s history by looking across the providers that the member has seen in the past."

In the future, the consulting firm plans to add more predictive analytics to the system to forecast potential high-cost patient cases, with outcome variables like the risk of future hospitalization. Using a regression model, the system will rank members by their probability scores. Using predictive analytics will help health plans, for example, reach out to female members who have a low probability of proactively scheduling their own examinations, based on their prior care histories.

"SAS is extremely valuable for extremely complicated heath care analysis," concludes Lieberman. "It requires superior data management capabilities and SAS' ability to do procedural language programming is essential. There are significant technical advantages to using SAS for this sort of work – we would not be this far in such a short amount of time without using SAS."

Challenge

To help US health plans meet the federal government's quality-of-care targets, as well as qualify for Medicare incentives, Health Data Essentials' clients needed a system to track their performance against quality-of-care metrics.